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<title>预约</title>
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<SCRIPT  type="text/javascript" src="public/js/date/WdatePicker.js"></SCRIPT>
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<div class="secbox">
	<h1>网上预约挂号</h1>
	<div class="view" style="display:none;"></div>
	<DIV class="ghright border1">
		<DIV class=secpath style="HEIGHT: 40px">网上预约挂号<A name=hao></A></DIV>
		<DIV style="PADDING-LEFT: 90px; LINE-HEIGHT: 20px; HEIGHT: 45px">
			<STRONG>温馨提示：您提交的个人信息将进行保密处理，祝您早日康复！<BR>
　 
　　　		&nbsp;请真实、准确的填写以下信息，才能<STRONG>成功</STRONG>挂号，按约就诊：
			</STRONG> 
		</DIV>
		<TABLE style="MARGIN-LEFT: 30px" cellSpacing=3 cellPadding=0 width=600 border=0>
			<FORM   method="post" name="meet_form"  id="ghform" action="list_Meet.php"> 
				<TBODY>
					<TR>
						<TD align=right width=136 height=30>
							<FONT color=#ff0000>*</FONT> 患者姓名:&nbsp;&nbsp;		
						</TD>
					<TD width=461>
							<INPUT  type="text" class="ghinput" maxLength=30 name=username id="uname" value="请输入您的姓名">
							<strong id="usermsg"></strong>
						</TD>
					</TR>
					<TR>
						<TD align=right height=30>年龄:&nbsp;&nbsp;</TD>
						<TD><INPUT class=ghinput maxLength=30 name=age id="age"></TD>
					</TR>
					<TR>
						<TD align=right height=30>性别:&nbsp;&nbsp;</TD>
						<TD>
							<INPUT type=radio value="0" name=sex checked="checked">
								男　
							<INPUT type=radio value="1" name=sex>
								女
						</TD>
					</TR>
					<TR>
						<TD align=right height=30>就诊科室:&nbsp;&nbsp;</TD>
						<TD><INPUT class=ghinput readOnly value=胃肠专科 name=ks></TD>
					</TR>
					<TR>
						<TD align=right height=30><FONT color=#ff0000>*</FONT> 联系电话:&nbsp;&nbsp;</TD>
						<TD><INPUT class="ghinput" maxLength=30 name=tel id="tel" value="请输入手机或电话号码">
							<strong id="telmsg"></strong></TD>
					</TR>
					<TR>
						<TD align=right height=57>病情描述:&nbsp;&nbsp;</TD>
						<TD><TEXTAREA style="WIDTH: 400px; HEIGHT: 50px" name=cont></TEXTAREA></TD>
					</TR>
					<TR>
						<TD align=right height=30>就诊日期:&nbsp;&nbsp;</TD>
						<td><input class=ghinput  name="yul"  onclick="WdatePicker();" onfocus="this.select()"  />
						</td>
					</TR>
					<TR>
						<TD align=right height=26>&nbsp;</TD>
						<TD vAlign=bottom><INPUT type=button value=现在提交 name=Submit id="sub"></TD>
					</TR>
			</FORM>
			</TBODY>
		</TABLE>
	</DIV>
	
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